D epartment
of
M edicine
Con ne c ti ng T e c h n o lo g y , Ed uca t i o n a n d Di s c ove ry w ith H um anis m in Me dicine
Vol. 5, Issue 4: Oct. 2016
REACT: A Resource for Patients Discharged from the Hospital
An estimated thirty-five million patients were discharged after admission to the hospital in the United States alone in 2010. Amongst the Medicare population, approximately 20% of patients were readmitted within 30 days. This high frequency of readmissions prompted the launch of multiple nationwide initiatives to investigate and improve hospital discharge processes. Here at UTMC, we responded to this need with the creation of the Rapid Evaluation and Care Transition (REACT) Clinic. REACT Clinic provides hospital follow-up appointments for patients recently discharged from UT Medical Center. Named
by Dr. Jack Lacey, then-Chief Medical Officer, the REACT Clinic launched in July 2015 in an effort to bridge care between the inpatient and outpatient settings. The primary goals are to clarify medication changes and discharge instructions, check repeat labs, and transition patients back to their primary care providers. Timely hospital follow-up is a crucial aspect to patient care. Hospitalizations far too often inadvertently inundate patients with new diagnoses, unfamiliar terminology, and multiple medication changes. Discharge instructions can be extensive continued on page 2 and overwhelm patients. Despite the
Points of View
him safely to Earth.” This “moon shot,” as it is widely known, encapsulated the aspirations of the nation, set a definite goal, and a timetable to achieve it by. The collective efforts of many resulted in the moon landing on July 20, 1969 and Neil Armstrong became the first man to walk on the moon, thereby fulfilling President Kennedy’s prophecy and firmly establishing the pre-eminence of the United States in space. During his State of the Union address earlier this year, President Obama announced a “moon shot” on cancer. The initiative to find a cure for cancer is led by Vice President Joe Biden whose son, Beau, succumbed to brain cancer last year. This initiative will focus the energies of cancer researchers all across America and the world to find better methods for preventing and treating cancers in children and adults. continued on page 2 We hope these efforts will be just as
In the spring of 1961, Yuri Gagarin, a Soviet cosmonaut, became the first man in space. This event led to the widespread perception that the Soviet Union was ahead of the United States in the “Space Race.” President John F. Kennedy was determined to demonstrate that the U.S. was a leader in space exploration. In a speech to a joint session of Congress he proposed Rajiv Dhand, MD, Chair that… “This nation should commit itself to achieving the goal, before this decade is out, of landing a man on the Moon and returning 1
Early Screening for Lung Cancer By Dr. J. Francis Turner, MD Lung cancer is a terrible disease. Hearing that you or a loved one has been diagnosed with lung cancer brings out the emotions of fear, hopelessness, and loss. Lung cancer is the leading cause of cancer death in the United States, with more deaths per year than breast, colon, and prostate cancer combined. Moreover, it is an insidious disease with approximately 85% of lung cancers diagnosed after metastasis or local growth that precludes a surgical cure. This means 433 Americans die of lung cancer every day, which would roughly be the equivalent of a jumbo jet full of passengers crashing each day in the United States. Research into lung cancer continues. A landmark study published in the New England Journal of Medicine in 2011 demonstrated early detection, by low dose CT scans of the lung, helped find early lung cancers and decreased mortality by 20% in some smokers and former smokers. The evidence was such that the Centers for Medicare and Medicaid Services authorized payment for these CT scans in smokers between 55 to 77 years old who had smoked the equivalent of a pack per day for 30 years and were currently smoking or had quit within the last 15 years. To ensure accurate interpretation and the availability of the latest advances in the diagnosis, staging, and treatment of this deadly disease, the University of Tennessee Medical Center, in cooperation with the University of Tennessee Graduate School of Medicine, has developed an Early Lung Cancer Detection Program in partnership with multiple specialists. This multidisciplinary approach assures that the patient receives multiple opinions regarding their care from all the disciplines involved in the diagnosis, treatment, and personalized care every patient with lung cancer deserves. We hope this coordinated multispecialty care, in association with the ongoing research at the medical school and Cancer Institute of the University of Tennessee Medical Center, will give each patient the best chance and hope in the fight against lung cancer. For more information, contact Teresa McDonald, Nurse Navigator of the Early Lung Cancer Detection Program at 865-305-5385
REACT
continued from page 1
best efforts of the team that discharges the patients, patients find themselves faced with a plethora of questions after they leave the hospital. REACT Clinic serves as an opportunity for these patients to voice their questions and concerns. While hospitalizations resolve acute issues, healing is not limited to physical ailments. Experienced residents comb through patients electronic medical records in order to provide patients with clarity and understanding about their illness and medications. Patients are not the only ones who benefit from REACT. Dr. Juli Williams, Director of the UT Internal Medicine Resident Clinic, notes “REACT Clinic is a wonderful educational experience for our residents and provides the community with an invaluable resource.” The efforts of all participants in the REACT Clinic will hopefully result in a decrease in the frequency of readmissions to the hospital. Patients are contacted within 2 days of hospital discharge and have a follow-up appointment within 7-14 days. Experienced internists supervise these third-year residents in the clinic.
Points of View
continued from page 1
successful as the proposal to land a man on the Moon. As we start on the journey to find a cure for cancer, it is worth remembering President Kennedy’s words. In one of the most famous speeches of all time delivered at Rice University in September of 1962, President Kennedy reiterated his conviction to go to the Moon. He said “We choose to go to the Moon!. . .We choose to go to the Moon and do the other things, not because they are easy, but because they are hard; because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one that we are unwilling to postpone, and one we intend to win. . .” We can be certain that finding a cure for cancer by 2020 will present stiff challenges, but I’m sure these challenges will be overcome! 2
Putting Best Practices into Medicine Efficient use of health care resources means better patient care, but it takes effort and creativity to integrate expert guidelines into practice. For example, eliminating unnecessary telemetry use has the potential to reduce unnecessary nursing tasks, reduce “alarm fatigue” (desensitization to alerts due to overuse), and save money. It can also contribute to patient comfort and safety and, in some cases, to patient confidence in their readiness for discharge. The 2004 American College of Cardiology and the American Heart Association (ACC/AHA) clinical practice guidelines stratify patients into three classes, with corresponding recommendations for telemetry. “Here at UTMC, our internal medicine residents recommend telemetry use in 80% of admissions, and our hospitalists average about 90% telemetry use,” explained Dr. Jaime Morris, PGY-3. “Based on the ACC/AHA guidelines, this is a significant amount of unnecessary telemetry.” Hospitalists and internal medicine residents use the General Medicine pathway to admit patients, which includes a default setting for telemetry. Dr. Jaime Morris, Dr. Kayleigh Litton (Cardiology fellow) Dr. Dale Wortham (Fellowship Director, Interventional Cardiology) and Dr. Trey LaCharité (UT Hospitalist) proposed modifications to the electronic ordering system to guide telemetry use based on AHA criteria. The General Medicine Pathway now contains a drop down menu in which the practitioner selects the telemetry option that is consistent with the AHA guidelines. “These changes took effect in July,” said Dr. Morris. “We will review data in November in consideration of publication.”
Welcome to In Touch, Dr. Ehlers! We are fortunate to welcome Dr. Azaria Ehlers, PGY-2, as our new resident contributor for In Touch. “I enjoy talking with people and finding out what interesting things they are doing,” she says. She was drawn to medicine because she enjoys finding ways to help people understand their health and what they can do to improve it. “I’ve always wanted to help people. When someone comes to you with a problem and you can figure out what’s wrong and how to make them feel better – that’s what it’s all about.” Azaria has an interest in health literacy and health education. She believes that meeting people “where they are” and using words and concepts that are familiar to them are keys to empowering them to make positive lifestyle changes. Born and raised in Iowa, Azaria has enjoyed her first year in East Tennessee. She loves to travel and has been all over Europe. Her favorite place so far? “St. Petersburg in Russia. It is rich in history, and the architecture is simply stunning.” She also loves to bake (and eat) anything chocolate. She likes to work in the hospital setting and plans to be a hospitalist after residency.
New Additions to Department Staff Kimberly Givens, Jennifer Ferris, and Ashley Hull We are pleased to introduce Kimberly Givens, the new manager of the Department of Medicine. Kim comes to us from the University of Tennessee. She has her Master’s degree in Public Health and served at the Joint Institute for Computational Sciences. We also welcome Jennifer Ferris who recently joined the department as Clinical Trials Research Coordinator. Ferris has over 10 years of experience as a Clinical Research Coordinator. She will be responsible for shepherding protocols through the Institutional Review Board process, budgeting, enrolling patients, and processing the trials. As our fellowship programs have and continue to expand, we created a new position for an Kimberly Givens Jennifer Ferris Ashley Hull Administrative Specialist to work with Pam Trentham. This position was filled by Ashley Hull, who brings several years of GSM experience. We are excited to welcome all three new staff members, and look forward to the enhancements they will bring to our department.
Honors
Each year a panel of health care leaders choose the year’s Health Care Heroes. This year Dr. John H. Dougherty, Jr., Clinical Associate Professor of Medicine, was chosen as one of the recipients of this prestigious award for his career-long work on detecting and managing Alzheimer’s disease. We would also like to recognize Dr. James Shamiyeh, Clinical Assistant Professor of Medicine, for becoming the Medical Director of the Heart Lung Vascular Institute on October 1, 2016. 3
New Program Director for the Cardiovascular Fellowship
Retirement – Jane Obenour The Department of Medicine wishes to congratulate Jane Obenour on her retirement on August 4th. Jane provided over 16 years of exceptional service to the Department of Medicine. She will be greatly missed by her coworkers, faculty, and residents.
Dr. Bret Rogers assumed the role as the new Program Director for the Cardiovascular Fellowship Program. Dr. Dale Wortham will now serve as Program Director for the new Interventional Cardiovascular Fellowship Program.
New Faculty We are excited to welcome five new faculty members to the Department of Medicine. Three of these faculty (Drs. Michael Carringer, Bradley Davis, and Benjamin Helms) currently practice with UT Hospitalists and will work with the residents on our new Hospitalists Team.
Michael Carringer, MD
Bradley Davis, MD
Benjamin Helms, MD
Ronald Hamrick, MD
Mahmoud Shorman, MD
Dr. Carringer completed his residency in internal medicine in the UT Department of Medicine. He is a two-time recipient of the Rawson Award for outstanding clinical and teaching skills. He also holds a US Patent. Dr. Davis completed his internal medicine residency in the UT Department of Medicine. He served as a College of Medicine representative at the 2007 Donors Gala and was chief resident from 2010 to 2011. Dr. Helms completed his internal medicine residency in the UT Department of Medicine. He has received numerous awards including the Clinical Medicine Award, the Arnold P. Gold Foundation Humanism Award, the Excellence in Teaching Award, and the Rawson Award. He also served as chief resident. Dr. Ronald Hamrick practices with Dermatology Associates of Knoxville and in our resident’s clinic. He completed residencies in internal medicine and dermatology at the University of Minnesota Medical School. He was a chief resident in his last year. Dr. Mahmoud Shorman will provide coverage with our Infectious Disease faculty. He completed his residency in internal medicine at New York Medical College at Metropolitan Hospital Center. He also completed a rotation in transplant infectious diseases at Vanderbilt University. We are very privileged to add these talented faculty members to our teaching staff.
CME Opportunities—Mark Your Calendars!
• Weekly Cardiology Conferences, generally held on Wednesdays each week for .75 hour CME credit. • Medicine Grand Rounds, which are generally held on the 2nd and 4th Tuesdays of each month for 1.00 hour CME credit. • Ethics Case Rounds, which are held on the 4th Thursday of the month at noon in Wood Auditorium, are available for 1.00 hour CME credit. 4
Ethics Case Rounds
In Touch
Ethics Case Rounds are monthly, hospital-wide discussions of morally distressing cases. Cases are de-identified to protect patient confidentiality.
Vol. 5, Issue 4: October 2016
“Unwise? Incapacitated? Or Just Different?” Dr. Juli Williams had been concerned about her clinic patient, Sam, a 75-year-old gentleman who lived alone in an apartment, for a long time. His unsteady gait and occasional seizures had contributed to several falls, sometimes resulting in fractures. He was malnourished and his diabetes and hypertension were poorly controlled, though he insisted he’d been taking care of himself. His affect was perpetually flat, and he seemed to have some cognitive decline. He was also very guarded and distrustful of others. Dr. Williams was not entirely surprised when Sam was admitted in severe diabetic ketoacidosis, with blood sugars above 1000 and a hemoglobin A1C level of 19.
Publishers James Neutens, PhD, Dean Rajiv Dhand, MD, Chair, Department of Medicine and Associate Dean of Clinical Affairs
Once stabilized, Sam would not allow, much less participate in, his care. He refused medication, labs, baths, and sometimes even food. He hated hospitals and refused to go to a nursing facility, even temporarily. However, he was so deconditioned that if he went home he would likely die (or come right back to the hospital). He said he has no family, though he does have a friend, Mike, who lives down the hall, who is also elderly and in poor health. Dr. Collins, then PGY-2, requested an Ethics Consult. Sam did not appear to have decision-making capacity for discharge planning, as he could not articulate the risks of going home in his condition, or explain how he was going to meet his basic needs. The team considered the possibility that Sam would simply prefer to accept this as the end of his life rather than continue to live in a nursing home facility, but Sam himself rejected this: “Don’t be stupid. I just want to go home.” He does not want Mike to be his surrogate decision maker. “He’s crazier than I am.” Given the high likelihood of grave consequences if he were to go home, together with his inability to demonstrate understanding or acceptance of these consequences, the team filed a petition with the State to consider whether Sam needed a court-appointed guardian to make decisions on his behalf. While Adult Protective Services (APS) was working on their investigation, there was an unexpected development: Sam’s sister, Berthe, contacted the hospital. When asked if he had a sister, Sam admitted that he did. He did not object to the team discussing his care with her. In a meeting with Dr. Collins, the liaison from APS, and Ethics, Berthe, offered her opinion that the best plan would be for him to go home with as much support as possible, including Home Health and engaging Sam’s friend Mike to help keep track of his well-being, even though he would still be at risk for becoming ill or dying. She believed Sam would be at risk for falling at home, and probably would not follow his medication regimen very well, but stated he also “wouldn’t last a month” in a nursing home because he would become despondent and “just give up.” APS agreed to follow closely, but would not seek custody for the time being. Sam agreed to allow Berthe, Home Health, Mike, and APS to help him at home. Berthe came in to the hospital to learn how to give his insulin. Sam was discharged home, and has not had to be readmitted since. Comments on this case may be sent to amendola@utmck.edu • Carese, JA “Refusal of Care: Patients’ Well-being and Physicians’ Ethical Obligations. ‘But Doctor, I Want to Go Home’” JAMA. 2006;296(6):691-695. doi:10.1001/jama.296.6.691 • Stewart, R; Bartlett, P; and Harwood, RH “Mental capacity assessments and discharge decisions” Age and Ageing (November 2005) 34(6): 549-550
Presentations, Publications, Awards Department of Medicine faculty, residents, and fellows share their knowledge and experience by publishing and presenting across the world. For a list of our most recent accomplishments, visit http://gsm.utmck.edu/internalmed/scholars.cfm.
Thank You For Your Support For information about philanthropic giving to the UT Graduate School of Medicine, Department of Medicine, please contact the Development Office at 865-305-6611 or development@utmck.edu. If you would like more information about any of the topics in this issue of In Touch, please contact the Department of Medicine at 865-305-9340 or visit http://gsm.utmck.edu/internalmed/main.cfm. We look forward to your input. Thank you.
Stay In Touch! Alumni, please update your contact information by completing the simple form at http://gsm.utmck.edu/internalmed/alumni.cfm or by calling the Department of Medicine at 865-305-9340. Thank you! 5
Editor Annette Mendola, PhD Administrative Director Susan Burchfield, CAP-OM Contributors Susan Burchfield Rajiv Dhand, MD Kandi Hodges Annette Mendola, PhD Azaria Ehlers, MD Kimberly Givens Design J Squared Graphics In Touch is produced by the University of Tennessee Graduate School of Medicine, Department of Medicine. The mission of the newsletter is to build pride in the Department of Medicine by communicating the accessible, collaborative and human aspects of the department while highlighting pertinent achievements and activities. Contact Us In Touch University of Tennessee Graduate School of Medicine Department of Medicine 1924 Alcoa Highway, U-114 Knoxville, TN 37920 Telephone: 865-305-9340 E-mail: InTouchNewsletter@utmck.edu Web: http://gsm.utmck. edu/internalmed/main.cfm The University of Tennessee is an EEO/AA/Title VI/ Title IX/Section 504/ADA/ ADEA institution in the provision of its education and employment programs and services.